7/2/2013

A special thanks to. . .

Principles of Postural Restoration® „ Chris Poirier and Perform Better

for the Sports Clinician

Perform Better Functional Training Summit:

„ Each of you here today
Chicago, IL
June 28-30, 2013
„ My sponsors. . .
Michael J. Mullin, ATC, LAT, PTA, PRC – Every patient I’ve seen in the
OA Centers for Orthopaedics past 12 years
mmullin@orthoassociates.com

What is posture? What is Postural Restoration?

POSTURAL RESTORATION INSTITUTE®

„ Posture is a reflection of the position of many
systems that are regulated, determined and created
through limited functional patterns. These patterns
reflect our ability and inability to breathe, rotate and
rest, symmetrically with the left and right
hemispheres of our axial structure.
„ Ron Hruska
„
(PRI)
– Concepts and science developed by
Ron Hruska, PT
– Institute and Hruska Clinic located in
Lincoln, NE
PRI® PRINCIPLES
„
– To explore and explain the science of
postural adaptations, asymmetrical
patterns and influence of polyarticular
chains of muscles on the human body
– To develop an innovative treatment
approach that addresses the primary
contributions of postural kinematic
movement dysfunction

Polyarticular chains
Polyarticular chains
Dominance on Left vs Right sides

„ Brachial Chain (BC) „ Pulling empirical and “evidence-based” information from multiple
– Sternocleidomastoid, Scalenes, sources from a myriad of different sciences, the Left and Right sides of
Sibson’s Fascia, Deltoid-Pectoral, the body truly work differently on many levels
Anterior-Lateral Intercostals,
Triangularis Sterni, Diaphragm „ The Left Anterior Interior Chain is the dominant pattern
– Referred to as the L AIC
„ Anterior Interior Chain (AIC) „ Driven by overactive Left psoas and iliacus, Right hemidiaphragm, Left TFL and
– Diaphragm, Iliacus, Psoas, TFL, vastus lateralis, Right bicep femoris and adductors
Vastus Lateralis, Biceps Femoris
„ Posterior Exterior Chain (PEC) „ The Right Brachial Chain is the dominant pattern
– Referred to as the R BC
– Posterior Intercostals, Serratus „ Driven by overactive Right hemidiaphragm, Left pectoralis, Right triangularis
Posterior, Latissimus Dorsi, sterni, Right abdominal obliques
Quadratus Lumborum, Iliocostalis
Lumborum „ The Posterior Exterior Chain is overactivity of the back extensors, lats
„ Tempro-Mandibular Cervical and QL’s
– Underneath this PEC is a L AIC and R BC in hiding
Chain (TMCC)

www.posturalrestoration.com

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What does L AIC and R BC What does history suggest about ingrained,
imbalanced polyarticular chains?
look like in life? “This PRI-stuff is new, isn’t it?”

„ Right-sided dominance „ Contrapposto

regardless of hand and foot
dominance – Italian-”opposite”
– Driven by our brains, „ A sculptural scheme in which the
nervous system, respiratory standing human figure is poised
system, visual system, such that the weight rests on one
circulatory and lymphatic leg (“engaged leg”) freeing the
systems, etc. other leg which is bent at the knee
„ Right “stance” with Left – L AIC stance
trunk counter-rotation most
common – R BC counter-rotation
– Can still be standing and
weightbearing on Left leg
but pelvis and lumbar spine
is oriented to the Right
– Trunk counter-rotation to
the Left at the level of the
diaphragm to balance out
the system

What does it look like in athletics? What does it look like in athletics?

„ Googling the words „ Using arrows to

“soccer change of demonstrate
direction”, these dynamically what is
were the first happening, this is
pictures shown. what’s going on
biomechanically. . .

What does it look like in athletics? What does it look like in athletics?
Googling the words “soccer cutting” Running

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What does it look like in athletics? What does it look like in athletics?
Running Turning sports

Note the Right vs Left shoulder height, lordosis, and

different scapula position
Also, in Left stance, limited Left trunk sidebend (thoracic
abduction) vs Right side in Right stance

What does it look like in athletics?

Throwing sports
What does it look like in athletics?

What does it look like in athletics? How about with Olympic lifts?

Left stance loading response Right stance loading response Which leg is doing the Please. . .someone spot
lifting here? this guy. . .anyone

3

What does the literature say about asymmetry?
¾ “Development of scoliosis is
connected with ‘gait’ and
habitual ‘standing at ease’
on the Right leg”
(Biomechanical aetiology of the so-
called idiopathic scoliosis: New
clinical and radiological
classification. Karski, TK, Journ US-
China Med Sci, May, 2011).
What’s driving it ?
„ Our asymmetrical
anatomical systems
– Organs, nerves, respiratory
system, vision
„ How we breath
– Overinflated, hypertonic
„ Habits, patterns, and
position
– ADL’s, position of ease
„ Society
– Media
What’s going on inside?
Respiratory action
„ As we inhale, our diaphragm is
supposed to inferiorly “pull” the air in
(negative pressure), concomitantly
through the belly and rib expansion
– There should be fairly equal
distribution into the entire thorax
– The ribs should remain fairly neutral
anterior to posterior
– Eccentric contraction of abdominals
and pelvic floor
„ As we exhale, the diaphragm slowly
returns to its domed shape and helps
“push” the air out of out lungs
– Considered to be a passive activity
with regular tidal breathing
„ Making it active is training these
muscles
– IR and depression of anterior ribs
The fuller the exhalation, the more IR
„
– Concentric raising of the pelvic floor
and abdominals (TrA, IO’s and EO’s)
„ “The LBP group had
significantly less total
rotation and more
asymmetry of total rotation,
Right hip versus Left hip,
than the NoLBP group. Left
total hip rotation was more
limited than Right total hip
rotation in the LBP group.”
(Hip Rotation Range of Motion in
People With and Without Low Back
Pain Who Participate in Rotation-
Related Sports. Van Dillen LR, et al,
Phys Ther Sport, May, 2008).
„ Ultimately looking to
„ Since the three main
7/2/2013
What does the literature say about asymmetry?
„ Right-footed turns have a
longer time for the entire
turn, longer time during
both phases of the turn,
shorter prep time for Right-
vs Left-footed turns
– Also greater magnitude of
force with Right-footed
turns
– Right-footed turns more
carving and Left-footed
turns more parallel style
„ Vaverka F, Vodickova S. Laterality
of the Lower Limbs and Carving
Turns. Biology of Sport, 2010;
27(2): 129-134
What’s going on inside?
Respiratory structures
„ Diaphragm
– Right has a larger, thicker and
stronger central part (leaflet)
– Right has three tendon
(central crura) attachments to
the lumbar spine (L1, L2, L3)
while the Left has two (L1, L2)
– Right is more superiorly
orientated than the Left
– Right is structurally supported
by the liver
– Phrenic nerve is longer on the
Left side
„ 3 lobes in the Right lung, 2
lobes in the Left
„ The Right diaphragm pulls
air into the Left side and
vice versa
What’s going on inside?
Respiratory action
achieve a Zone of
Apposition—that aspect
of the diaphragm that
apposes the chest wall—
in the respiratory cycle in
which the diaphragm
returns to its domed
shape
– A fuller exhaled state
with pause is the key
way this is produced
ways we create stability in
our system is position,
muscle, and pressure,
this ZOA allows the
position of the muscles to
be optimally oriented for
gasseous pressure
exchange
Images used with Permission
© Postural Restoration Institute®
www.posturalrestoration.com
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What’s going on inside? What’s going on inside?

Boney structures
Respiratory action

„ Left hemi-pelvis is anteriorly

tipped and forwardly rotated
– Due to hyperactivity of the Left
psoas driven by the Right
diaphragm
„ Right hemi-thorax is anteriorly-
inferiorly positioned (internally
rotated) vs the Left side
– Produces Left lower rib flares
greater than on the Right and
larger rib angles on the Left
– Left scapula adducted/superior
orientation on thorax and Right
depressed
– Left scapula downward rotation
and ER while Right is upward
rotated and IR (winging vertebral
border)

What does this asymmetry produce? What does this asymmetry produce?
Visual observations Visual observations

„ Increased lumbar „ Curvature of the

lordosis spine
– Right posterior
„ Anterior inferior rib rib hump
flares common
– Typically L > R „ Left foot more
– Often increased left pronated, Right
rib angle as well foot more
„ Uneven shoulder supinated
height and often „ LL Cool J-itis
different scapula
orientation

www.posturalrestoration.com

What does this asymmetry produce? How do you assess for it?
Assessments R BC Tests

„ Inability to touch toes „ Humeral-Glenoid IR

– Supine hooklying, arm out at
„ Inability to squat fully to 90° and elbow bent 90°
the floor with heels – Press on the anterior shoulder
down, knees in to stabilize then rotate the arm
alignment and feet into IR
straight www.posturalrestoration.com – Compare both sides
– Limitation on one or both sides
„ Decreased left hip IR (R > L) of the fingers being
and right hip ER able to touch the table
suggests poor positioning of
– Often the same total ROM thoraco-scapula
on both sides but in – Poor balanced diaphragmatic
www.posturalrestoration.com

different amounts of IR breathing control!

and ER

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How do you assess for it? How do you assess for it?
R BC Tests R BC Tests

„ Shoulder Horizontal „ Apical Expansion Test

Abduction
– Supine hooklying, arm out at 90°
with patient/client at the side of a
table
– Bring the arm into pure
horizontal abduction and check
for limitations, comparing both
sides
– Limitation on one or both sides
(L > R) suggests poor
positioning of thoraco-scapula
– Poor balanced diaphragmatic
breathing control!
– Supine, hooklying, hands on
inferior ribs on one side,
depressing posterior medially
– Client/patient exhales and the
ribs are depressed further
– Maintain this pressure as the
client/patient re-inhales
– Looking for ability to apically
expand the opposite chest wall
– Limitation on one or both sides
(↓ R expansion when pressing
on L side) suggests poor
www.posturalrestoration.com
www.posturalrestoration.com balanced diaphragmatic
breathing control!
– If bilateral, than they likely have
other issues as well

How do you assess for it? How do you assess for it?
L AIC Tests L AIC Tests

„ Adduction Drop Test „ Extension Drop Test

– Similar to Ober Test – Similar to Thomas Test
– Client/patient sidelying with knees – Both legs are passively brought
bent 90° to the chest and one leg is
– Stand behind and passively flex, lowered off the end of the table,
abduct, and extend the hip to making sure to not let thigh
neutral while stabilizing the pelvis
with the other hand abduct past 0°
– Important to maintain good – A positive test is indicated when
positioning of the femur over the the femur—on the LEFT side
acetabulum with a L AIC—cannot extend to
– To determine joint centration the table
– Positive test for L AIC = LEFT thigh – Again, often correlates to a +
does not drop to the table (adduct) Adduction Drop Test on the
– Often correlates to + L Ext Drop LEFT
Test on the LEFT as well „ If the hip can’t extend, it can’t
„ If the hip can’t extend, it can’t adduct!
adduct!
– If bilateral, than they are a PEC
– If bilateral, than they are a PEC www.posturalrestoration.com
www.posturalrestoration.com

How do you assess for it? How do you assess for it?
L AIC / R BC / PEC combined tests L AIC / R BC / PEC combined tests

„ Functonal Squat Test „ Standing Reach Test

– Performed two different
– Graded on a scale of ways
Levels 1 – 5 „ Reach straight down
– Different than other „ Reach down with Right
hand overlapping Left
common squat tests as it towards Left toes
is performed with trunk – Rounded back is
flexion, knees go encouraged
forward of toes, and – Exhalation while reaching
heels must stay down – Measure both from tips of www.posturalrestoration.com
without a block to fingers to floor
assist!! – Should be able to touch
toes in both scenarios

www.posturalrestoration.com

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What about the PEC?
This is what it looks like. . .
. . .and this is often why
„ Over activity of the back
extensors coupled with
hyperinflation produces marked
tone. . .and not necessarily
good tone!
What should be done to correct these imbalances?
„ After establishing a ZOA,
especially on the Left (getting
more air in on the Right), the
system needs to be
repositioned to get them more
neutral
„ Need to go after the upper
hamstrings, adductors and IR’s
(Left), then GMax (Right), then
obliques (Left) in the corrected
position!
„ Then have them hold each
exercise for 4 breaths with full
(not forced) exhalation then
pause. . . .
„ Consider it activation methods
for pre-performance work
What should be done to correct these imbalances?
Left sidelying Right GluteMax
Starting position
Images used with Permission
© Postural Restoration Institute®
www.posturalrestoration.com
7/2/2013
What do you do to manage it?
L AIC / R BC
„ Get your clients / „ Training them to learn to
patients to breathe inhale with proper
diaphragmatically expansion and exhale
– Need to establish a Zone with control is integral to:
of Apposition by getting
– reducing unwanted
the diaphragm to move
pressure in the system
properly, especially on the
Left side – creating good joint position
– Fuller, not forced, – optimizing muscle activity
exhalation with warm-ups – improving performance
and muscle prep activities
What should be done to correct these imbalances?
Left sidelying knee toward knee Left sidelying knee toward knee
Starting position Finish position
Images used with Permission
© Postural Restoration Institute®
Images used with Permission www.posturalrestoration.com
© Postural Restoration Institute®
www.posturalrestoration.com
What should be done to correct these imbalances?
Opening/expanding the posterior mediastinum
Left sidelying Right GluteMax Starting position Finish position
Finish position Inhale while rounding back Full exhalation while bringing
sternum to ceiling
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What should be done to correct these

What should be done to correct these imbalances?
imbalances?
Finish position
Exhale with Right trunk rotation
Starting position/inhale and R hip ER and R leg reach „ After performing the
Opening/expanding the
exercises in a more
stable position to
posterior mediastinum get them more
neutral, stand them
up and perform
some exercises in
the corrective
position.
„ Again, integrate
breathing with this.

What should be done to correct these imbalances? What should be done to correct
these imbalances?

„ Introduce more „ Then get them up for

unilateral bias their movement prep
and warm-up drills
activities to really with a bias towards
get the pelvis and the corrected
hip/trunk muscles position.
integrated.
„ Cues are:
– Slide your Left thigh
back
– Bring your Left
lower ribs to your
pelvis
– Exhale with control

What should be done to correct these imbalances? What should be done to correct these imbalances?
Integrating into standard workouts Integrating into standard workouts

Left hemi-pelvis is posteriorly . . .with Left thoracic “crunch”

rotated. . . (abduction)

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What should be done to correct these imbalances? What should be done to correct these imbalances?
Integrating into standard workouts Integrating into standard workouts

PRI is about reciprocal . . .preferably in a

activity. . . corrected position Push-pull sequences. . . . . .for reciprocal activity

What should be done to correct these imbalances? What should be done to correct these imbalances?
Integrating into standard workouts Integrating into standard workouts

Push-pull sequences for . . . in a corrected Push-pull sequences for . . . in a corrected

reciprocal activity. . . position reciprocal activity. . . position both ways

What about when they are training? What about when they are training?

NO! NO! NO! NO!

Bad bicep curls Bad bicep curls

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What about when they are training? What about when they are training?
Good bicep curls examples Good bicep curls integration
Better! Left leg posterior shift
Good, body weight centered stagger stance, trunk
over feet, reciprocal crunch, reciprocal

What about when they are training? What about when they are training?
Triceps presses examples Lat pull downs examples

NO! YES! Overextended. . .over-latted Good, balanced control

What about when they are training?

What about when they are training?
Corrective cues

Not recommended. . .or at least finish with twice as Cues to shit into Left hip and
many in the complete opposite way with… Dynamic valgus loading response bring torso forward
Left leg and pelvis back, trunk counter-rotated Right

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What about when they are training?

Conclusion. . .
Cueing for optimal results

„ Careful evaluation and assessment of movement strategies is

imperative for all athletes and clients.
„ It is important to consider the underlying patterns which may
be driving some of your evaluation findings and consider
biasing some of your training sessions accordingly.
„ Integration of optimal breathing patterns coupled with
corrective exercise strategies to reduce overactive movement
patterns will improve results
„ Consider taking courses from Postural Restoration Institute to
further your understanding of this:
– Myokinematic Restoration
– Postural Respiration
– Pelvis Restoration
„ www.posturalrestoration.com
“Where do you feel it?”

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